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De-Mythifying DoD/VA Billing and Reimbursement Issues. [Name Redacted] OASD, Health Budgets and Financial Policy March 2006. Authorities. Public Law 97-174 and 107-31 Title 38, Section 8111 and Title 10, Section 1104 DoD Instruction 6010.23

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de mythifying dod va billing and reimbursement issues

De-Mythifying DoD/VA Billing and Reimbursement Issues

[Name Redacted]

OASD, Health Budgets and Financial Policy

March 2006

authorities
Authorities
  • Public Law 97-174 and 107-31
  • Title 38, Section 8111 and Title 10, Section 1104
  • DoD Instruction 6010.23
      • Department of Defense and Department of Veterans Affairs Health Care Resource Sharing Program
  • 1983 MOU between VA and DoD on sharing which says the rate will take into account local conditions and actual costs.
  • NDAA 2003 – mandated standardized reimbursement rates for DoD/VA sharing
general principles for dod va reimbursement
General Principles for DOD/VA Reimbursement
  • Methodology will be agreed to by both Departments
    • Not the same as billing TPC
    • Does not use the Interagency Rate
  • Provide flexibility to take into account local conditions and actual costs (actual = incremental)
  • Funds will be credited to the providing facility
general principles for dod va reimbursement1
General Principles for DoD/VA Reimbursement
  • Per NDAA for FY 2003, rates will be standardized and waivers are allowed
  • 2003 MOA - basic agreement to use price-based methodology of discounted CMAC or TRICARE rates
  • 2003 MOA states no GME reimbursement for direct sharing agreements
  • Joint Ventures have choice to use or not use standard rates depending on local sharing arrangements
  • Standardized methodology does not apply to TRICARE network contracts with VA
outpatient rates cmac less 10
Outpatient RatesCMAC less 10%
  • Began implementation in October, 2003
  • Professional fee plus ancillary and pharmacy
  • If no CMAC available…
    • CMS rate
    • Negotiate substitute rate based on incremental cost
  • Guidance did not address ambulatory procedures (will be revisited soon)
  • Does not apply to reference lab agreements – use incremental cost instead
  • Should be separated from support/tenant services
inpatient methodology yet to be finalized
Inpatient Methodology Yet to be Finalized
  • TRICARE rates less 10% x DRG
    • TRICARE methodology for outliers
    • Guidance will address professional services, anesthesiology, mental health, durable medical equipment, transfer patients, ambulance service, waivers, etc.
  • Goal is to have guidance ready for HEC approval in April/May
why is this important
Why is This Important?
  • Increasing DoD/VA collaboration is a priority for the President and the Congress
    • NDAA 2003 created the Joint Incentive Program whose purpose is increased sharing opportunities
  • Office of Management & Budget scores our progress quarterly
  • Progress is reported bi-monthly to the Joint Executive Council (USD, P&R)
  • Joint Strategic Plan has goals and milestones for collaboration – progress reported annually to Congress